Building a Smart Proton Center that is both

Leading Edge Today and Maintains its Edge

in the Future

James M Metz, MD

Professor and Chair

Executive Director, OncoLink

September 24, 2017

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Disclosures

IBA Speaker Board

Varian Proton Advisory Board

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X

Scale Legend

0 200 400

Current and Future Treatment Sites for Proton Delivery in the US

Loma Linda

Univ Med Ctr

MGH

Existing Site

Under Construction

MPRI

PENN

U. FloridaMDACC

Oklahoma City

Hampton

Univ

Chicago

Scripps

SCCA Seattle

ProCure

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The Maturing US Proton Landscape

There are currently 24 operational centers in the US

5 facilities are now 7 years or older

Each facility has followed different upgrade paths

It is easy to ignore upgradability when in the purchasing

phase for a new center

Standardized upgradability plans from the vendor are critical

for long term success of a center

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Upgradability Should be Considered in Design

Linear Accelerators have a useful life of 7-10 years before

technology and wear and tear require replacement

Proton Centers, due to their massive investment, are planned

to last 40 years or more

Technology will change dramatically over this period of time

Consider Linear Accelerator technology 30-40 years ago- 2D

planning, simple fields, individual blocks, hand calculation for

treatment planning, wedges placed manually

Much of future developments will be due to improvements in

computer technology and imaging.

Space to integrate new technology is paramount- you can’t

add more later in most centers

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Earliest US Centers Approach to Upgradability

MGH- Built internal expertise to manage and upgrade center.

Now building new room with new technology to add to current

center

Loma Linda University- Build internal expertise to manage and

upgrade center. Working at limits of accelerator technology

MD Anderson- Considering adding second center with

scanned beam technology on same site as current center so

as not to shut down current operations

University of Florida- Adding new single room center with

latest scanning technology to the current facility

MPRI- Closed center due to expense to upgrade center to

Pencil Beam

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How Did Penn Approach Upgradability?

This was a key issue when we decided to build a proton center

We wanted to both build a state of the art facility and maintain

a state of the art facility through the life span

We formed an Executive Committee that included physicians,

physicists, and administrators- every decision impacts

clinical, technological, and cost

We visited every center that we could to understand the

challenges other centers experienced and shortcomings in

design

We questioned every vendor on their roadmap and future

vision

We formed an advisory board of outside experts to help us

project future developments

We looked at the developments in conventional radiation and

projected transfer of technology to protons

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How Did Penn Approach Upgradability?

We wanted maximum flexibility for the future

At a time of uncertainty for future delivery, we installed

Universal Nozzles that would give us clinical flexibility when

PBS was only in research and development facilities

We knew we could upgrade to a dedicated PBS nozzle if

needed in the future

We wanted to be capable of accepting new imaging modalities

such as CBCT, with limited impact on operations

Downtime should be kept to a minimum

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The Penn Journey

We signed a contract in 2006 to make sure we had maximum

flexibility to have the latest technology

We opened in 2010 as a next generation proton facility

We had a goal of maintaining that position as a leader in

technology for the proton system

At almost 8 years, the length of time you would replace a

linear accelerator, we have maintained that position with

upgrades.

We expect the scheduled upgrades over the next cycle of

typical hardware replacement will allow us to continue as a

leading center technologically.

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The Penn Journey- Current State

5 proton treatment rooms- 4 currently operational, 1 down for

upgrades

1 Fixed beam with a dedicated PBS nozzle

2 Gantry universal nozzle- now in PBS mode only

1 Gantry with Universal Nozzles DS/US- Now in DS mode only

1 Gantry - Down - being converted to dedicated PBS nozzle

(commissioning 10/17)

PBS made US obsolete in our facility

We feel PBS will make DS obsolete by 2018 in our facility

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Proton New Starts at Penn over 8 years

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New Upgrades in Proton Therapy at Penn

Adding one additional CBCT system this year to bring the total

to 3 CBCT’s

Changing one Double Scattering room to a dedicated PBS

Room (Estimated Completion 12/17)

Dual energy CT simulator (installed 4/17)

Taking down last Double scattered room and conversion to

PBS with CBCT (2018)

Proton Research Room (9/17)

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Gantry Mounted CBCT System

CBCT

Detector

43cm x 43 cm

CBCT X-

ray Tube

FOV: 34 cm axial and 34 cm longitudinal field of view

Rotation speed of 0.5 or 1 RPM (full scan or half scan)

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Proton Research Room

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New Penn RadOnc Proton and SARRP Research Facility: ”behind the wall”

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Upgrades to Proton Research Room

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New RadOnc Proton and SARRP Research Facility: Proton Beam & SARRP platform

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Vendors and Upgradability

Experience matters

Understand the upgrade plans of each vendor

Evaluate the demonstrated upgrades throughout their system

critically thus far (if available)

Some vendors are new and do not have a track record to

evaluate on upgrade path

Understand the operational effects of proposed upgrade path

Realize the team doing the upgrades is very different from the

team making the initial sale and installation

Beware of promises, promises, promises– take things into

your own hands on what you want

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A Few Final Thoughts

Maintenance and replacement of worn technology is critical

along with upgrades

Predictive analytics and diagnostics are important skill sets

for a vendor in a maturing facility

The onsite spare parts list needs to evolve as a facility

matures– it will be very different over time

Maintaining current operations of a busy center while

upgrading requires planning and collaboration with vendor

Long term success requires partnership, commitment, and

unwavering diligence

A well trained team on site that understands the nuances of

your system is critical while performing upgrades and

continued maintenance

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Annual Course on Proton Therapy: November 17-19 2017Target Audience

Radiation oncology physicians, physicists and

administrators who are interested in learning about proton

therapy.

Objectives

At the end of this educational activity, participants should

be able to:

• Understand the logistics of establishing a proton

therapy center with clinical and research capabilities

• Describe the current clinical indications and

applications for proton therapy

• Comprehend the various technical considerations in

proton therapy planning

• Explain the regulatory aspects of proton therapy

planning and delivery from the standpoints of quality

assurance and compliance

• Better perform their specific roles within the proton

center

Please ask your IBA representative for registration information:

https://protontherapycourse.cvent.com/events/annual-course-

on-proton-therapy/registration-

d2e7ae6f151c49aca17b36d8cc7727ea.aspx?fqp=true

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